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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807098
Report Date: 11/15/2019
Date Signed: 11/15/2019 01:11:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:DSUSD/JACKSON ECE CENTERFACILITY NUMBER:
334807098
ADMINISTRATOR:BLANCA CARRASCOFACILITY TYPE:
850
ADDRESS:82-850 KENNER STREETTELEPHONE:
(760) 775-3830
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY:47CENSUS: 34DATE:
11/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Sonya BarabinoTIME COMPLETED:
10:30 AM
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On the above date, Licensing Program Analyst (LPA) Timeka Reed arrived at the facility to conduct a case management visit. The purpose of the case management visit was to follow up on an unusual incident report submitted by the facility on October 18, 2019. The incident occurred on October 17, 2019.
According to the incident report, Child #1 (C1) was playing on the outside play structure, lost balance and then fell.
During the visit LPA took a census of the children present, and interviewed the teacher (Staff #1) that witnessed the incident. Subject child (Child #1) is no longer enrolled and was not available on this day.

During the visit, the LPA toured the facility's climbing structure and pictures were taken. The area surrounding the play structure was observed by LPA Reed to have appropriate cushioning material.

Based on all the information obtained by LPA Reed on this day, additional information is needed as C1 was not available to be interviewed.

An exit interview was held. A copy of this report was provided at the time of visit
SUPERVISOR'S NAME: Gilbert SenaTELEPHONE: (951) 782-4844
LICENSING EVALUATOR NAME: Timeka ReedTELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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